Does Idaho Smiles Cover Braces? Medical Necessity and Approval

Idaho Smiles does cover braces, but only for children enrolled in Medicaid or CHIP, and only when an orthodontist documents that treatment is medically necessary and MCNA Dental approves the request before work begins.¹ Adults on Idaho Medicaid are not eligible for orthodontic coverage.²

Who Qualifies

Orthodontic treatment is a covered dental service under Idaho administrative code only for Medicaid-eligible children, with MCNA Dental serving as the managed care contractor that reviews eligibility. The adult dental rule lists preventive, diagnostic, restorative, periodontic, prosthodontic, oral surgery, and endodontic services, but orthodontics is deliberately absent from that list.²

Children have an additional layer of federal protection. Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, states must provide medically necessary orthodontic services to Medicaid-eligible individuals under age 21.³ In Idaho, no service request for a child under 21 may be denied until it has been evaluated under EPSDT, even if the service is not ordinarily part of the state plan.⁴

What Counts as Medically Necessary

Wanting straighter teeth is not enough. The child’s condition has to meet the Idaho Medicaid Handicapping Malocclusion Index, and MCNA Dental makes the call.⁵

In practice, the orthodontist must submit the Index of Orthodontic Treatment Need (IOTN) form for Idaho providers as part of prior authorization.⁶ The IOTN scores severity on two scales: a Dental Health Component graded 1 through 5, and an Aesthetic Component scored 1 through 10. Higher grades mean more severe conditions. Cases rated Grade 4 or 5 on the Dental Health Component typically reflect conditions serious enough to warrant treatment on health grounds, such as significantly protruding teeth, impacted teeth, missing teeth requiring orthodontic correction, or a deep bite causing tissue damage.⁷

Reviews are conducted by licensed dentists on MCNA’s staff using nationally accepted clinical guidelines, including those from the American Academy of Pediatric Dentistry. If the orthodontist disagrees with a decision, they can request a peer-to-peer discussion.⁸

What Idaho Smiles Pays For

Braces and orthodontic retainers are both listed as covered services for children, with prior authorization required for each.¹

Coverage is for traditional metal braces. Clear braces, ceramic braces, and Invisalign are not paid for by the program, and families who want those options cover the extra cost out of pocket.⁹

How to Start the Approval Process

The paperwork is the orthodontist’s job, not the family’s. Providers submit prior authorization requests electronically through the MCNA Provider Portal and include the completed IOTN form along with supporting documentation.⁸

To find an in-network orthodontist, families can search MCNA’s provider directory at locator.mcna.net.¹⁰ The MCNA Member Hotline, 1-855-233-6262, is open Monday through Friday from 6:00 a.m. to 6:00 p.m. Mountain Time, with help available in English, Spanish, and other languages.¹¹

What Families Pay

Program documentation does not list specific copays or cost-sharing amounts for children’s orthodontic treatment.¹ Federal Medicaid rules generally prohibit or strictly limit cost-sharing for children, so approved treatment is typically at no cost to the family.

One practical warning: orthodontic treatment often runs two years or longer, and losing Medicaid or CHIP eligibility partway through can leave a family on the hook for the remainder. Settle payment terms with the orthodontist at the start, and ask directly what happens if coverage lapses mid-treatment.

If MCNA Denies the Request

Families have two levels of appeal.

The first is an internal appeal filed with MCNA within 60 calendar days of the denial notice. The family or the child’s dentist can submit additional clinical information supporting the need for treatment. Appeals can be filed by calling the Member Hotline or completing an appeal form on MCNA’s website.¹²

If the internal appeal fails, the next step is a State Fair Hearing through the Idaho Department of Health and Welfare, requested within 120 calendar days of the appeal decision. Hearings are generally conducted by telephone. Requests go to the Department’s Administrative Procedures Section by mail, fax, hand delivery, or email.¹²

Keep EPSDT in mind as a parallel route. No dental service request for a child under 21 can be denied without first being evaluated under EPSDT, and for dental requests families should contact MCNA directly rather than using the standard state EPSDT request form.⁴

1
InsureKidsNow.gov. Idaho Medicaid Dental Benefits Summary
2
Cornell Law Institute. Idaho Admin. Code r. 16.03.26.293
3
Medicaid.gov. Early and Periodic Screening, Diagnostic and Treatment
4
Idaho Department of Health and Welfare. EPSDT Information
5
Cornell Law Institute. Idaho Admin. Code r. 16.03.09.803
6
MCNA Dental. IOTN Form for Idaho Providers
7
British Orthodontic Society. What Is the IOTN
8
MCNA Dental. Idaho Smiles Dentist Resources
9
Post Falls Orthodontics. Idaho Medicaid Orthodontic Coverage
10
MCNA Dental. MCNA Provider Locator
11
MCNA Dental. Idaho Smiles Member Resources
12
MCNA Dental. Idaho Smiles Grievances and Appeals